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Ultrasound-Guided Treatment of Peripheral Entrapment Mononeuropathies John W

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Ultrasound-Guided Treatment of Peripheral Entrapment Mononeuropathies John W AANEM MONOGRAPH ULTRASOUND-GUIDED TREATMENT OF PERIPHERAL ENTRAPMENT MONONEUROPATHIES JOHN W. NORBURY, MD,1 and LEVON N. NAZARIAN, MD2 1 Department of Physical Medicine and Rehabilitation, The Brody School of Medicine at East Carolina University, 600 Moye Boulevard, Greenville North Carolina 27834, USA 2 Department of Radiology, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania, USA Accepted 13 May 2019 ABSTRACT: The advent of high-resolution neuromuscular ultrasound high-resolution linear-array transducers has allowed neu- (US) has provided a useful tool for conservative treatment of periph- romuscular US to emerge as a powerful tool for the diag- eral entrapment mononeuropathies. US-guided interventions require 2–6 careful coordination of transducer and needle movement along with a nosis of peripheral entrapment mononeuropathies. detailed understanding of sonoanatomy. Preprocedural planning and US-guided treatment of entrapment mononeuropathies positioning can be helpful in performing these interventions. Cortico- has also greatly expanded in recent years. Technical steroid injections, aspiration of ganglia, hydrodissection, and minimally invasive procedures can be useful nonsurgical treatments for aspects of performing therapeutic US-guided proce- mononeuropathies refractory to conservative care. Technical aspects dures and the current state of the science regarding US- as well as the current understanding of the indications and efficacy of guided treatment for common peripheral entrapment these procedures for common entrapment mononeuropathies are reviewed in this study. mononeuropathies are reviewed and discussed in this Muscle Nerve 60: 222–231, 2019 monograph. The expansion of high-resolution linear-array trans- TYPES OF ULTRASOUND-GUIDED INTERVENTIONS ducers has allowed neuromuscular ultrasound (US) Corticosteroid Injections. Corticosteroids suppress 7–9 to emerge as a powerful tool for the diagnosis and treat- proinflammatory cytokines. They are thought to exert ment of entrapment mononeuropathies. In general, a therapeutic effect in entrapment neuropathies by 10,11 these mononeuropathies can be caused by compression suppressing the associated inflammation and edema. at fibro-osseous tunnels, mass effect from adjacent gang- Althoughtraditionallyitwasthoughtthatsteroidsactvia lia, and sometimes biomechanical abnormalities, such as an effect on inflammation in the nerve itself, recent hypermobility or traction. Diagnosis can be made on clini- research suggests that vascular congestion plays a role cal grounds and confirmed by electrodiagnostic (EDx) and this may be decreased by corticosteroids, thereby 11 testing or neuromuscular US. Treatment options for alleviating symptoms. In addition to anti-inflammatory peripheral mononeuropathies include surgery; conserva- effects, a direct analgesic impact may also contribute to 12 tive measures such as education, splinting, nerve glide potency of corticosteroids. In the authors’ experience, exercises, and avoidance of provocative activities; as well the pain associated with entrapment neuropathies often as injection therapy. Until recently, these injections were has a better response to steroid injections than the performed without image guidance. Although blind neurologic symptoms such as numbness and especially injections for mononeuropathies are often efficacious,1 weakness. Absolute contraindications to corticosteroid they run the risk of either inadvertent nerve damage or injections include allergy to medication, active infection placement of the injectate in a location that may be too or wound in the area being injected, and severe hyper- far away to have maximum effect. The development of glycemia. Blood glucose levels can remain elevated for 5 days after a local corticosteroid injection, and a hemo- globin A1C greater than 7% is predictive of a higher and Additional supporting information may be found in the online version of 13 this article. longer lasting elevation in blood glucose levels. Abbreviations: CSA, cross-sectional area; EDx, electrodiagnostic; fl EMG, electromyography; FCR, exor carpi radialis; LCNT, lateral cuta- Hydrodissection, Aspiration of Ganglia, Phenol, or neous nerve of the thigh; NCS, nerve conduction study; PIN, posterior interosseous nerve; UNE, ulnar neuropathy at the elbow; US, ultrasound Alcohol Blocks, and Minimally Invasive Procedures. Key words: aspiration; corticosteroid injection; entrapment mononeuropathy; Recently, hydrodissection has been explored as an perineural injection; treatment; ultrasound guidance Available for Category 1 CME credit through the AANEM at www.aanem. adjunct to standard corticosteroid injections. In this pro- org. This paper underwent peer review by the AANEM Monograph Review cedure, a large (15 ml or less) volume of anesthetic, and Development/Issues & Opinions Committee and review by the Mus- fl cle & Nerve editor, but did not undergo additional peer review via the saline, or dextrose-containing uidisinjectedinthe Muscle & Nerve editorial process. perineural region in hopes of breaking adhesions that Conflicts of interest: None of the authors have any conflicts of interest to disclose. may be contributing to the mononeuropathy. Hydrodis- section (or hydroneurolysis) has been shown to reduce Correspondence to: J. W. Norbury; e-mail: [email protected] gliding resistance in the carpal tunnel in cadaver © 2019 Wiley Periodicals, Inc. 14 Published online 15 May 2019 in Wiley Online Library (wileyonlinelibrary. models. This technique may be especially helpful in com). DOI 10.1002/mus.26517 situations where scar tissue contributes to the pathology, 222 AANEM Monograph MUSCLE & NERVE September 2019 such as in recurrent carpal tunnel syndrome (CTS) Either a large-gauge needle17 or a modified surgical after a surgical release.15 An example of fluid dis- instrument18,19 can be used to actually release the nerve section of the median nerve from the transverse carpal by mechanically disrupting the structure causing the ligament and subsynovium is shown in the video (refer entrapment, such as the transverse carpal ligament. to Supplementary Material available online). Although these procedures are still relatively uncom- When a mass lesion such as a ganglion is present, mon, they may become an alternative to traditional sur- US-guided needle aspiration is a potential treatment. gical releases. Ganglia appear as cystic masses, often in association with joints or tendon sheaths, although they can also TECHNICAL ASPECTS OF ULTRASOUND-GUIDED be intraneural. They do not demonstrate Doppler INTERVENTIONS flow. Examples of ganglia that cause entrapment neu- US-guided needle placement to the perineural ropathies are shown in Figure 1. When aspirating a region requires coordination of transducer position ganglion, a large-gauge needle (such as an 18- or and needle location to deliver medication to the 16-gauge) is necessary as the contents of the ganglia appropriate location. Difficulty visualizing the needle will usually have a very viscous or jellylike consistency. before advancement and unintentional transducer Corticosteroids can be injected after the ganglion is movement make these procedures challenging for the decompressed, although the utility of corticosteroids novice operator.20 A variety of tools are available to for this indication has not been proven. assist with needle tracking such, as needle guides, Phenol and alcohol blocks have been used for lasers, and robotics (reviewed elsewhere).21 Both decades to treat spasticity related to upper motor neuron authors find it easier to have the same operator hold- injuries. For refractory painful entrapment mononeuro- ing the probe as well as the needle, although others pathies in nerves that only supply cutaneous sensation, find it easier to have 2 individuals performing the pro- such as the lateral cutaneous nerve of the thigh (lateral cedure. Real-time needle tracking can be divided into femoral cutaneous nerve), chemical neurolysis with “in-plane” and “out-of-plane” techniques (Fig. 2), both these agents can be an alternative to the more traditional of which have their strengths and weaknesses. Advan- surgical neurolysis. The downside, when compared with tages of the in-plane approach include the ability to corticosteroid injections, is that neurolysis will result in a see the needle shaft and tip during the entire proce- sensory deficit in the areas innervated by the nerve. dure and the ability to access both the superficial and There is also a theoretical risk of residual paresthesia deep aspects of nerves for hydrodissection. Advantages based on reports from the spasticity literature.16 of the out-of-plane approach include a more direct Recently, US-guided minimally invasive procedures access of some superficial structures and a less-steep have been developed for entrapment neuropathies. learning curve. The major disadvantage of the out-of- FIGURE 1. Examples of cysts that can be treated by US-guided drainage. (A) An example of a patient with a suprascapular neuropathy secondary to a spinoglenoid ganglion, which is bordered by the infraspinatus (IS) anteriorly, the scapula (S) posteriorly, and the humerus (H) laterally. (B) After drainage, the ganglion (asterisk) is barely visible. (C) A longitudinal view of an intraneural ganglion of the fibular nerve. Arrows point to the nerve on either side of the ganglion. AANEM Monograph MUSCLE & NERVE September 2019 223 FIGURE 2. Needle orientation with respect to the transducer. (A) An in-plane approach demonstrates
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